RELEASE OF LIABILITY WAIVER
This waiver is to be signed by adults participating in services and/or treatments
Acknowledgment and Assumption of Risk
I am aware of the dangers and the risks to my person and property involved in participating in any of the following services, Medical Weight Loss, Testosterone/ Hormone Replacement Therapy, Botox/ Dermal Fillers.
I agree to fully comply with the applicable laws, policies, rules and regulations, and any supervisor’s and/or Qualified Medical Provider's instructions regarding my participation in this program.
I understand that the State of Arizona (State) does not insure participants in the above-described activity, that any coverage would be through personal insurance, and the State has no responsibility or liability for injury resulting from this activity.
I voluntarily elect to participate in this program, and I hereby agree to accept and assume any and all risks of property
damage, personal injury, or death.
Waiver of Liability and Indemnification:
In consideration for being allowed to voluntarily participate in the above-referenced event, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever:
a. Waive, release, and discharge Vestra Health LLC, and its agencies, officers, and employees from any and all negligence and liability for any of my personal injury, property damages, death, disability, property claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event; and
b. Defend, indemnify, and hold harmless Vestra Health LLC, its agencies, officers and employees, from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from participant’s actions during this activity or event. I hereby give consent to receive medical treatments/services from Vestra Health LLC which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law. I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this
agreement.
c. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.
Informed Consent for Weight Management Program
Clients Voluntary Enrollment
I am voluntarily enrolling in the Vestra Health LLC Weight Loss Program. I hereby authorize Vestra Health LLC and its staff to provide support for me to achieve the goals of weight loss and weight maintenance. Such support may include but is not limited to obtaining a complete medical and weight history, a physical examination, appropriate laboratory screening, follow-up visits as per our office’s recommendations, direct phone calls, psychological therapy, nutritional counseling and vitamin supplementation.
Program Purpose and Risks of Obesity
The purpose of enrollment in the program is for the benefit of my overall health and to lose weight. Obesity and being overweight increases my risk for developing heart disease, diabetes, stroke, cancer, and many other diseases. It also reduces my overall life expectancy. I recognize these current risks to my health as unacceptable and wish to aggressively address my weight by enrolling in this program.
No Guarantees
I understand that no guarantee or representation has been made or given to me by anyone as to the results or outcomes of this weight management program. I understand that a major part of the success of the program will depend upon my own personal efforts in following the advice and recommendations I have received as a program participant.
Risks of the Program
I understand that there are some small risks to me in choosing to enroll in this program. These risks include but are not limited to the following:
1) Rapid weight loss
2) I may feel a slight burn during injections, it quickly subsides.
3) I understand that regular follow-up calls with your health coach and supervising doctor allows for early detection and management of these possible problems.
General Comments
I understand that in consenting for treatment I agree to pay in full for all visits and charges at the time of each visit. I understand that there are no refunds given at any time for any reason.
Insurance Billing
Health insurance companies do not pay for programs such as this one. I understand that I am personally responsible for payment of all services rendered at this facility for weight management. We do not bill any insurance company for any service rendered at this clinic. We will provide you with a receipt that includes the diagnosis code and charges recorded if you wish to attempt to obtain reimbursement for services rendered on your own including HSA and VEBA accounts.
FINANCIAL AGREEMENT
Congratulations and welcome to Vestra Health LLC, we are excited you are taking positive steps, and our commitment is in assisting you toward transforming your health with our program. We are very selective in who we decide to coach, and only accept health participants who are committed to the lifestyle changes and recommended protocols needed for health and healing.
It is illegal and highly unethical for any consultant to guarantee results for any health care condition, however, we can speak from experience, and the success rate we have witnessed has been tremendous. We are not treating your allopathic conditions, such as diabetes, heart disease or hypothyroid etc.; rather, we are supporting metabolic and functional imbalances as they are identified. We can assure you that we will do everything in our power to lead you to a favorable outcome.If monthly payments are being made and care is discontinued after your first initial paid evaluation appointment, there will be no refunds. Payments will be made until balance is paid off. Your consistency with our recommendations is very important to the success of this progra; therefore, any support within this program must be utilized within the agreed 9 weeks of inception of your financial agreement. Any communication or support not used during this time will be considered expired and invalid for use. Please note that the follow up appointments are at no cost and therefore are not included in the case fee. The ongoing support, which is at no cost to you, is designed to help and guide in the implementation of those protocols.
Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association under its Commercial Arbitration Rules. The place of arbitration shall be Phoenix, Arizona. Arizona law shall apply. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The decision of the arbitration will be legally binding. Either party may take no other method of legal action.
The appointments are either in person, via phone or telemedicine, and are not intended to treat disease, but to coach health participants back to a healthy life style. I understand that Vestra Health LLC conducts business in a virtual space, which means we support our clients in person or telephone.
We ask you to commit to 3 months. During this year the pay structure is as followed:
$599 Per Month - Monthly Pre Filled Syringes Delivered to your door, including initial consult and other fees.